Healthcare Provider Details

I. General information

NPI: 1124596390
Provider Name (Legal Business Name): OLIVE BRANCH AUTISM SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 SUNRISE BLVD STE 210B
CITRUS HEIGHTS CA
95610-7639
US

IV. Provider business mailing address

5750 SUNRISE BLVD STE 210B
CITRUS HEIGHTS CA
95610-7639
US

V. Phone/Fax

Practice location:
  • Phone: 916-794-2326
  • Fax: 916-626-4682
Mailing address:
  • Phone: 916-794-2326
  • Fax: 916-626-4682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ADAM OLIVES
Title or Position: BCBA OWNER
Credential: BCBA
Phone: 916-794-2326